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ZONING PERMIT APPLICATION www.countyofdane.conl SUPPLEMENT to Web•App# <br /> PROPERTY OWNER INFORMATION _ CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> CI vIn is -k-- (��) e j v-c.. Kv.4- et+e r ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City:State,Zip) <br /> L/ � ��\I ft_ � � C � Deed Restriction; CSM ) <br /> O eA_ b k A4 c W ( .S 35 L3 Variance(# <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Cools $SI 4500Y 3to co -2 15 ❑Site Plan drawn to scale <br /> 'AGENT INFORMATION - . CONTRACTOR-INFORMATION _ and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Ross n Cs, h 5 ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> Fc ,-t w-1-1 ,, tnl t <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> S-3S3fi' <br /> PHONE , PHONE 9A0- 5-43 cf v411 ❑ Site Plan approval from <br /> 9a o _ 4,56 o l 3 9 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS ❑ Floor plans to scale <br /> gdw",-`a�`I.FQr gimil d IH 'o w. <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us!) . ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENTZONING: ACREAGE: <br /> ❑PARCEL 06 )Z '36 _'73)0 A---'L 20.... 15-1 frontage drawn to scale. <br /> NUMBER (� <br /> TOWNSHIP: ( ' SECTION: <br /> G b V r l sot 7�' 1/a: � ' IA: El Driveway permits <br /> S (state, county,town) <br /> ADDRESS: , /' <br /> 6-771" �T ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> —. ___-__. (public private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 1 A X yo IN\c>Lk,., n r S hrd ❑ Zoning Dlstnct w,. <br /> . ❑This project is a new building or structure. ❑ Permitted_Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ RUral Address , <br /> EWER 1EPTIC (new/existi ng) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> . ) i ( ❑ Wetand/Foodplaln/ _ <br /> AREA TO NEAREST SQUARE FOOT: :-- .and (attachment) =` <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ �DSIOnCont l permit <br /> BASEMENT: • 1ST FLOOR: + '.� <br /> / J_ 1/ TOTAL SQUARE FOOTAGE: SlO es-disturbance, <br /> LQ 1 j yfim IhngiaccessJ .1-4,�`"�t_ <br /> 2ND FLOOR: 3RD FLOOR: - a't'-�41��< 4 <br /> b �0 ❑ Review Location-Survey <br /> ESTIMATED CONSTRUCTION COST: 1� and available-optionS <br /> (Please round to nearest dollar) "'� ♦ ♦ ♦ ♦ ♦ 7 T/ S g <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No • Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [, ]Yes ❑No LIDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®Yes ON <br /> 4.'Has there been a zoning permit issued for this property in the past 5 years? � ❑Yes [ENO . <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# G79CJ ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) / Dies �No ❑Don't know <br /> 7. Is this to correct a violation? [Yes IZNo <br /> r' APPLICATION MUST BE SIGNED <br /> 2J. l `� (Continue on Back) -► -► -► <br /> 545-112(4/08) . <br />